Loading...
HomeMy WebLinkAboutResolution - 2011-R0313 - Contract - HMS Employer Solutions - Self-Insured Health Care Claims Auditing - 07/27/2011Resolution No. 2011—RO313 July 27, 2011 Item No. 5.3 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for and on behalf of the City of Lubbock, Contract No. 10144 for Self -Insured Health Care Claims Auditing Services, by and between the City of Lubbock and HMS Employer Solutions of Jeffersonville, IN, and related documents. Said Contract is attached hereto and incorporated in this resolution as if fully set forth herein and shall be included in the minutes of the City Council. Passed by the City Council on July 27, 2011 F V9'0*;"Z TOM MARTIN, MAYOR ATTEST: Rebecc -arza, City Secretary APPROVED AS TO CONTENT: 6hh Andy B chain, Chief FinanceOfficer APPROYEP AS TO FORM: Chad Weaver, Assistant City Attorney vwxcdocs/RES.Contract-HMS Employer Solutions June 28, 2011 CONTRACT 10144 Resolution No. 2011-R0313 CONTRACT This professional services contract is executed this 27th day of July, 2011 by and between the City of Lubbock, Texas, hereinafter called the City, and HMS Employer Solutions. WHEREAS, the City has issued a Request for Proposal (RFP 11 -10144 -DT) for Self - Insured Health Care Claims Auditing Services; and WHEREAS, the proposal submitted by HMS Employer Solutions has been selected as the proposal which best meets the needs of the City to provide such professional services; WITNESSETH: IN CONSIDERATION of mutual promises of the parties contained herein and other good and valuable consideration, the parties agree as follows: HMS Employer Solutions shall provide the City with the necessary professional services to audit all funds including those which are covered under the provisions of the Single Audit Act. 2. The term of the contract shall run from the date of execution and shall complete the audit within one -hundred and eighty (180) working days. The City and the contractor may, upon written mutual consent, extend the term by providing written notice of its intent not less than forty-five (45) days prior to the end of the term. The professional audit services shall be provided in accordance with the terms and conditions set forth in the Request for Proposal, attached hereto as Exhibit C. An engagement letter will be executed by authorized representatives of both parties, attached hereto as Exhibit A and HIPPA Business Associate Agreement, attached hereto as Exhibit B. 4. HMS Employer Solutions shall be compensated for services rendered under this contract in accordance with the terms and conditions set forth in Exhibit A. The City shall reimburse travel, lodging or meal expenses according to the IRS Department of Treasury Publication 1542, Per Diem Rates. 5. No work shall be performed beyond the present scope of this contract without express prior approval by the governing body of the City. 6. The City or HMS Employer Solutions shall have the right to terminate the contract upon 30 days written notice. 7. Neither party may assign any of its rights or delegate any of its obligations under this agreement, without the express written consent of the other. It is agreed that the failure of any party to invoke any of the available remedies under this agreement or under law in the event of one or more breaches or defaults by any QTurchase/BidDocs/11-14144-DT Contract party under the agreement shall not be construed as a waiver of such provisions and conditions and shall not prevent the parties from invoking such remedies in the event of any future breach or default. 8. Each paragraph of this agreement is severable from all other paragraphs. In the event any court of competent jurisdiction determines that any paragraph or subparagraph is invalid or unenforceable for any reason, all remaining paragraphs and subparagraphs shall remain in full force and effect. 9. This agreement shall be interpreted according to and enforced under the laws of the State of Texas. 10. This agreement contains the entire agreement of both parties hereto, and no other oral or written agreement shall be binding on the parties hereto. This agreement supersedes all prior agreements, contracts and understandings of any kind between the parties relating to the subject matter hereof. This agreement may be executed in one or more counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same instrument. IN WITNESS WHEREOF, the parties hereto have executed this professional services contract on or as of the date first written above. CITY OF LUBBOCK HEALTH MANAGEMENT SYSTEMS, INC. dba HMS Employer jSolutions By: Tom Martin, Mayor Donna PriceSe r Vice President ATTEST: -Q AaAAC-1- Rebe a Garza, City Secreta APPROVED AS TO CONTENT: aj4a� kq Jvt�- An� Leisa Hutcheson, Director of Human Resources And Risk Management A 7rtz; M: Assistant City Attorney Q:PurchaselBidDocsr11-10144-DT Contract Resolution No. 2011-R0313 EXHIBIT A CLAIMS AUDIT LETTER OF ENGAGEMENT 1. Scone of Examination. HMS will perform an Examination of the documents, books, files, and/or other records pertaining to the Claims Administrators, identify any overpayments, and investigate whether the Claims Administrators have properly accounted for pricing discounts in the pricing of claims charged to Client and Plan beneficiaries for claims paid starting on an agreed upon date determined during the Planning Phase and continuing through the most currently available data as of the time the Examination begins. The Examination will be conducted in accordance with the proposal. 2. Client Obligations. Client will pursue its rights to examine the paid claims and supporting documentation and shall cooperate with all reasonable requests by HMS during the Examination. HMS shall not be held financially responsible for provision of Examination service if Client is prevented from conducting the Examination by the Claims Administrators. Client shall make available to HMS all non -privileged books and records required by HMS to perform the Examination as described hereunder including, but not limited to, all documents subsequent to the effective date of the Agreement and related to savings or recovery from or settlements with Claims Administrators, credits, reimbursements, offsets, deductions, debt forgiveness, reductions in administrative fees and charges in favor of Client, and/or claims against, or damages or judgments from Claims Administrators. 3. Audit Methodologies and Process Overview. Client will submit medical claims paid from the agreed upon date determined during the Planning Phase. Client and HMS will mutually agree on the methods or means by which HMS conducts the Examination. In the event that Client and HMS enter into an agreement with any Claims Administrators arising from the Examination, such agreement with Claims Administrators will be proposed in a format recommended by HMS and mutually agreed-upon by the Parties. HMS shall issue to Client a report of its findings from the Examination ("Audit Report'). As soon as possible, but not later than upon the issuance of the Audit Report, Client and HMS shall promptly and diligently pursue recovery from Claims Administrators of all amounts to which HMS reasonably determines Client is entitled. HMS shall not, without the prior written consent of Client: (a) take any action adverse to the interests of any of Client's current or former employees or plan beneficiaries including, but not limited to, the pursuit of any recovery from Claims Administrators or the institution of any legal proceeding or claim against Claims Administrators; or, (b) hire or retain legal counsel, accountants, or other consultants or experts in pursuit of recovery from Claims Administrators. Client shall have the sole discretion and authority, after consultation with HMS, to settle or litigate claims against Claims Administrators. Neither Client nor HMS shall conclude any settlement or compromise any claim with Claims Administrators without prior written notice to and consultation with the other. HMS will regularly apprise Client of the status of the Examination, provide Client with all information relating to the Examination which Client reasonably requests, consult with Q Purchase/BidDocs/11-10144-DT Contract Client before beginning, include Client in any negotiations with Claims Administrators for recovery of any amounts to which HMS determines Client is entitled, and terminate the Examination at the direction of Client, pursuant to Section 8. HMS does not. guarantee or warrant that any recovery will be received from or settlement reached with Claims Administrators. 4. Examiner Exclusive . Until the Agreement is terminated pursuant to Section 8, HMS shall have the exclusive right and authority to conduct audits and to pursue recoveries and savings from Claims Administrators on behalf of client as described above, by such methods and in such manner as HMS deems appropriate. 5. Confidential Information. "Confidential Information" includes: a) certain Examination information, including information linking a diagnosis to a specific beneficiary of the Plan and other individually identifiable information, which is subject to legal privacy requirements (specifically, HIPAA requirements), a violation of which may harm Client, Claims Administrators, and/or Plan beneficiaries; b) the methodologies and procedures utilized by HMS in conducting the Examination; and c) such specific proprietary financial or business information as Client or HMS designates as "Confidential." The Parties shall comply with all legal privacy requirements referred to herein and shall not disclose, directly or indirectly, to any third party, any Confidential Information described in this Section. These provisions relating to Confidential Information described in this Section shall survive, and remain in effect for six (6) years after, the termination of the Agreement. The parties acknowledgment that this agreement is subject to the Texas Public Information Act and that any request for information received by the City of Lubbock shall be responsible to conforming with the Texas Public Information Act 6. Fees. Client shall pay HMS on the following terms, for services rendered to Client: ❑ $55,800 to be paid in equal installments for the following milestones: o 30% due upon contract signing o 70% due upon the delivery of the Draft Audit Report. ❑ The proposed pricing above will be honored for a term of 60 days from 6/28/11 and expires thereafter if not executed. ❑ Travel expenses as incurred are in addition to the above fees. QTurchase/BidDocO 1 -10144 -DT Contract 7. Independent Contractor and Compliance. HMS shall perform its services hereunder as an independent contractor and not as an agent or employee of Client. As such, the conduct and control of the Examination conducted by HMS shall lie solely with HMS. HMS shall comply with all applicable laws and governmental rules and regulations. HMS shall have no authority, without the prior written consent of the Client, to use the logos or trademarks of Client or its parent, affiliates or subsidiaries for any purpose other than fulfilling its responsibilities under the Agreement. 8. Indemnification. HMS shall indemnify, defend and hold harmless Client and its directors, officers and employees from and against any and all claims, liabilities, losses or damages, including reasonable attorney's fees, which arise from HMS's intentional or negligent acts during its performance under this Agreement. To the extent allowed by law, clients shall indemnify, defend and hold harmless HMS and its directors, officers and employees from and against any and all claims, liabilities, losses or damages, including reasonable attorney's fees which arise from Client's intentional or negligent acts during its performance under this Agreement. 9. Notices. All notices required hereunder shall be in writing and deemed given when mailed, certified U. S. Mail, postage prepaid, to the address below: If to Client: L 1 o 1L 13 ►.' Le' 54 Hufdv!5c-,7 c . tB"x 2 Lqu s7 If to HMS: HMS Employer Solutions 355 Quartermaster Court Jeffersonville, IN 47130 ATTN: Donna Price, Senior Vice President 10. Nonfiduciary. The Parties understand and agree that the Agreement does not grant HMS any authority or control, discretionary or otherwise, respecting management of any employee benefit plan of Client nor any authority or control respecting the management or disposition of any plan assets, that HMS is not rendering investment advice for a fee or other compensation, direct or indirect, with respect to any moneys or other property of any plan, nor does HMS have any authority or responsibility to do so, and HMS has no discretionary or other authority or discretionary or other responsibility in the administration of any Plan. HMS is not a fiduciary of the Plan and owes no fiduciary duties to Plan Participants. QTurchaserBidDacsll 1 -10144 -DT Contract. 11. Modification and Intenwetation. This Agreement constitutes the entire understanding of the parties concerning the subject matter and no changes, amendments or alterations hereto shall be effective unless in writing and signed by the Parties. The adjudged invalidity of any term shall not affect the validity of any remaining terms. The Agreement is clear and there are no ambiguities in any material respect. The Agreement may be executed in counterparts and electronic or facsimile representations are valid if original. The laws of the State of Indiana shall govern the validity, interpretation and enforcement of the Agreement. The Parties are fully aware of the contents and effects of the Agreement, and its execution and delivery are not the result of any coercion, fraud, duress, mistake or undue influence. 12. Publicity. HMS may include Client's name in its client list, and either party may issue press releases regarding the existence, or general non -confidential business terms of this Agreement, subject to prior written approval of the other party, which approval shall not be unreasonably withheld. IN WITNESS WHEREOF, the Parties have entered into the Agreement effective as of the date written above. HEALTH MANAGEMENT SYSTEMS, INC. DBA HMS EMPLOYER SOLUTIONS D�-w a D a Price Title: Senior Vice President Date: t 9N Q Purchase/BidDocs/l1-10144-DT Contract CITY OF LUBBOCK, TEXAS A tc_:1 e n Title. <<e`k-o•c o� V mam I6sm eces Date: q 2,0 ` ( Resolution No. 2011-RO313 Exhibit B HIPAA Business Associate Aureement This HIPAA BUSINESS ASSOCIATE AGREEMENT (the "Agreement") is made effective the July 14, 2011, by and between City of Lubbock, Texas, as Plan Sponsor ("Client"), by and on behalf of the City of Lubbock, Texas Health Insurance Plan, ("Covered Entity"), and Health Management Systems, Inc, dba HMS Employer Solutions, ("Company"), (each individually, a "Party" and Client and Company together, the "Parties"). WHEREAS, Client and Company have entered into an agreement ("Service Agreement") through which Company will provide dependent eligibility review services on behalf of Covered Entity ("Services"); and WHEREAS, in connection with provision of the Services, Company may have access to Protected Health Information, or PHI, as defined below, that is subject to restrictions and obligations under the Health Insurance Portability and Accountability Act of 1996, as amended ("HIPAA") and the American Reinvestment and Recovery Act of 2009 ("ARRA"); and WHEREAS, the Parties now desire through this Agreement to amend those provisions of the Service Agreement pursuant to which Company may have access to Protected Health Information, to comply with HIPAA and ARRA, and regulations issued thereunder as set forth in Title 45, Parts 160, 162 and 164 of the Code of Federal Regulations ("HIPAA Regulations"). THEREFORE, in consideration of the Parties' continuing obligations under the Service Agreement, and other good and valuable consideration, the Parties agree as follows: 1. Definitions. The following definitions shall serve to define the terms used within this Agreement. Capitalized terms used, but not otherwise defined in this Agreement or the Service Agreement, shall have the meanings given to them in the HIPAA Regulations. (a) "Breach" shall mean the acquisition, access, use or disclosure of PHI in a manner not permitted under the HIPAA Privacy Regulations which compromises the security or privacy of the PHI. (b) "Business Associate" shall have the meaning of the term "business associate" as defined at 45 CFR 160.103, and for purposes of this Agreement, shall refer to Company. (c) "Covered Entity" shall have the meaning of the term "covered entity" as defined in 45 CFR 160. For purposes of this Agreement, Covered Entity shall refer specifically to Covered Entity as defined above. Q:Purchase/BidDms/ 11- 10144 -DT Contract (d) "Designated Record Set" means a "designated record set" as such term is defined in 45 CFR Section 164.501 containing PHI that is created, acquired, received, used, maintained or accessed by Company, its employees, agents or representatives. (e) "Discovered" shall mean the first day upon which a Breach is known to the Company, or, by exercising reasonable diligence should have been known to the Company. (f) "Electronic PHI" means "electronic protected health information" as such term is defined in 45 CFR Section 160.103. (g) "HIPAA" means the Health insurance Portability and Accountability Act of 1996, as amended and as such may be further amended from time to time, including all interim final rules, final rules and regulations promulgated thereunder. (h) "HIPAA Breach Notification Regulations" means the federal regulations under ARRA requiring, among other things, the provision of notification of breach of Unsecured Protected Health Information and as incorporated into the Privacy Rule at 45 CFR Parts 160 and 164, as amended, and as such may be further amended from time to time. (i) "Individual" means "individual" as such term is defined in 45 CFR Section 164.501 and shall include a person who qualifies as a Personal Representative in accordance with 45 CFR 164.502(g). 0) "Privacy Rule" means the federal privacy regulations under HIPAA as contained in 45 CFR Parts 160 and Part 164, as amended, and as such may be further amended from time to time. (k) "Protected Health Information" or "PHI" means "protected health information" as such term is defined in 45 CFR Section 164.501. For purposes of this Agreement, PHI shall be limited to PHI created, acquired, accessed, maintained, used or disclosed by Company, its employees, agents or representatives from or on behalf of the Covered Entity. (1) "Required by Law" means "required by law'' as such term is defined in 45 CFR Section 164.501. (m)"Secretary" means the Secretary of the U.S. Department of Health and Human Services or her designee. (n) "Security Incident" means "security incident" as such term is defined in 45 CFR Section 164.304. Q: urchase/BldDoes/11-14144-DT Contract (o) "Security Rule" means the federal security standards under HIPAA as contained in 45 CFR Parts 160, 162 and 164, as amended, and as such may be further amended from time to time. (p) "Transaction Rule" shall mean the federal standards for electronic transactions under HIPAA as contained in 45 CFR Parts 160 and 162, as amended, and as such may be further amended from time to time. (q) "Unsecured PHI" means "unsecured protected health information" as such term is defined in 45 CFR Section 164.402. For purposes of this Agreement, Unsecured PHI shall be limited to Unsecured PHI created, acquired, accessed, maintained, used or disclosed by Company, its employees, agents or representatives, from or on behalf of Covered Entity. 2. Obligations of Business Associate. Company agrees to abide by the terms of this Agreement and comply with the applicable provisions of the Privacy Rule with respect to any PHI that Company creates, acquires, receives, uses, maintains, accesses, or discloses in connection with the Service Agreement. (a) Company agrees that it will use or disclose PHI solely for meeting its obligations as set forth in the Services Agreement and this Agreement or as otherwise approved by the Covered Entity. (b) Company will ensure that its agents, including any subcontractors, to whom Company may provide PHI agree to the same restrictions and conditions that apply to Company with respect to such information. In addition, Company agrees to take reasonable steps to ensure that its agents' actions or omissions do not cause it to breach the provisions of this Agreement. (c) Company shall provide sufficient HIPAA training to its employees, agents and representatives to whom it provides access to PHI in order for such employees, agents and representatives to fully understand and comply with Company's HIPAA obligations under this Agreement. (d) Company agrees to implement appropriate safeguards to prevent any use or disclosure of PHI by Company or its agents other than as permitted in this Agreement. (e) Company will report to Covered Entity any use or disclosure of PHI that is not permitted under the terms of this Agreement of which Company becomes aware. (f) Company agrees to mitigate, to the extent practicable, any harmful effect that is known to Company of a use or disclosure of PHI by Company, its employees, agents or representatives in violation of the requirements of this Agreement. (g) Company agrees to make available PHI in accordance with Covered Entity's policy and the requirements of Section 164.524 of the Privacy Rule. Effective Feb. 17, Q:PurchasefSidDocs'l 1 -10144 -DT Contract 2010, such right to copy and inspect shall include a right to an electronic copy of PHI that is maintained or stored in an electronic format and a right of Plan participant to direct that such record be provided to an entity or person designated by Plan participant, consistent with ARRA. (h) Company agrees to make PHI available for amendment and incorporate any amendments to PHI in accordance with Covered Entity policy and the requirements of Section 164.526 of the Privacy Rule. (i) Company agrees to make PHI available for purposes of accounting for disclosures in accordance with Covered Entity policy and the requirements of Section 164.528 of the Privacy Rule. 0) Upon termination of this Agreement for any reason, Company agrees either to return to Covered Entity or to destroy all PHI that is in the possession or control of Business Associate or its agents in any form and retain no copies of such PHI; or if return or destruction is not feasible, extend the terms and conditions of this Agreement to such information and limit further uses and disclosures to those purposes that make return or destruction of the information infeasible for as long as such PHI is retained. (k) The Secretary of Health and Human Services shall have the right to audit Company's records and practices related to use and disclosure of PHI to ensure Covered Entity's compliance with the terms of the HIPAA Regulations. 3. Security Rule Compliance. (a) Safeguards. Company shall implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the Electronic PHI that it accesses, creates, receives, maintains, uses or transmits on behalf of the Covered Entity as required by, and as more specifically set forth in, the final Security Rule. Effective Feb. 17, 2010, Company shall have implemented and shall maintain for the term of this Agreement safeguards including written policies and procedures under 45 CFR 164.316 that fully comply with the administrative standards of 45 CFR 164.308, the physical standards of 45 CFR 164.310, and the technical safeguards of 45 CFR 164.312 (b) Security Incidents. Company agrees to report in writing to the Covered Entity any Security Incident by Company or any of its agents or representatives relating to Electronic PHI. 4. Transaction Rule. To the extent the Services involve Company conducting, or assisting the Covered Entity in conducting, electronic transactions governed by the Transaction Rule, Company agrees it will not: (a) Change the definition, data, condition, or use of a data element or segment in a standard as required by 45 CFR § 162.915; (b) Add any data elements or to Q:Purchas6BidDocsl1 1 -I0144 -DT Contract segments to the maximum defined data set as required by 45 CFR § 162.915; (c) Use any code or data elements that are either marked "not used" in the standard's implementation specification or are not in the standard's implementation specification(s) as required by 45 CFR § 162.915; and (d) Change the meaning or intent of the standard's implementation specification(s) as required by 45 CFR § 162.915. 5. Breach Notification for Unsecured PHI. (a) Obligation to Exercise Reasonable Diligence. Company shall exercise reasonable diligence to detect any Breach of Unsecured PHI, and provide training and procedures through which its employees, agents and representatives are encouraged to detect and report to Company any Breach of Unsecured PHI. (b) Upon any "breach" of "unsecured PHI" in Company's control or possession affecting a Plan participant, Company shall notify Covered Entity as soon as possible after discovery of a breach; provide any ARRA-required notice to an affected Plan participant (with any such communications subject to the approval of the Covered Entity, which approval shall not be unreasonably withheld); provide any ARRA-required notice to a government agency; and provide any ARRA-required notice to a media outlet (with any such notice and the release of it subject to the approval of the Covered Entity, which approval shall not unreasonably be withheld). Further, with respect to any breach of PHI in Company's control or possession, Company shall promptly notify Covered Entity of any such breach; explain to Covered Entity any relevant state law notice or other obligations with respect to such breach; comply with all state notice or other laws applicable to such breach; and reimburse the Client or Covered Entity for any reasonable expenses incurred in meeting their state law obligations in responding to the breach. 6. Termination for Cause. 6.1 Termination for Cause. If the Covered Entity becomes aware or is notified of a material breach of this Agreement or a Breach of Unsecured PHI by Company, its employees, agents or representatives, the Covered Entity may: (a) Provide Company with an opportunity to cure the breach or end the violation within ten (10) days of receiving notice of the breach and/or violation, and, if such action does not successfully bring about cure of the breach or an end to the violation within the time specified by Covered Entity; shall terminate this BAA and the underlying contract or relationship under which the Company or Business Associate has access to, uses or disclosed PHI on behalf of Covered Entity; or (b) Immediately terminate this BAA and the underlying contract or relationship under which the Company or Business Associate has access to, uses or disclosed PHI on behalf of Covered Entity; if cure of the breach or causing the violation to end is not possible; or (c) If neither termination nor cure is feasible, Covered Entity shall report the violation to the Secretary. QTurchaw/SidDocO 1 -10144 -DT Contract Effective Feb. 17, 2010, the provisions of this Sec. 6.1 shall apply to both parties in the event that either becomes aware of a breach of this Agreement by the other. 7. Notice to Covered Entity. Any notice required under this BAA to be given to Covered Entity shall be made in writing to: C-11 6.( L4Abboek, hLe-i SG YLtc ew V'0 . Uox Zi a r " DCk, R jig .52 8. Notice to Company or Business Associate. Any notice required under this BAA to be given to Company or Business Associate shall be made in writing to: Alexandra Holt Chief Privacy and Compliance Officer 401 Park Avenue South New York, NY 10016 (212) 857-5337 aholtnhms.corn 9. Amendment. At the request of the Covered Entity, Company agrees to take such action as is necessary to amend this Agreement from time to time as is necessary for the Covered Entity to comply with its HIPAA obligations. If the Covered Entity and Company do not agree upon such amendments in a timely manner in order to ensure that the Covered Entity continues to comply with its HIPAA obligations, the Covered Entity may terminate the Service Agreement and this Agreement immediately by providing Company with prior written notice. 10. Interpretation. Any ambiguity in this Agreement shall be resolved to permit the Covered Entity to comply with HIPAA. If there is any conflict between the terms of this Agreement and the terms of the Service Agreement, the terms of this Agreement shall control. 11. Rights in Third Parties. This Agreement shall not create any rights in any third parties. 12. Survival. The obligations under this Agreement survive the expiration, termination, or cancellation of this Agreement and/or the Service Agreement, and shall continue to bind Company and its agents, employees, contractors, successors, and assigns as set forth herein. 13. Inconsistencies with the HIPAA Regulations. In the event of an inconsistency between the provisions of this Agreement and mandatory provisions of the HIPAA Regulations, as amended, or their interpretation by any court or regulatory agency with authority over Covered Entity or Company hereto, the HIPAA Regulations, as interpreted 12 Q: Purchase/Bi&Docs(1 I -10144 -DT Contract by such court or agency, shall control. Where provisions of this Agreement are different than those mandated in the HIPAA Regulations, but are nonetheless permitted by such rules as interpreted by relevant courts or agencies, the provisions of this Agreement shall control. IN WITNESS WHEREOF, the Parties have executed this Agreement as of the day and year written above. 633-ViNIV "I CLIENT: HEALTH MANAGEMENT SYSTEMS, CITY OF LUBBOCK, TEXAS INC. DBA HMS EMPLOYER SOLUTIONS DPT�w L-'%.� (�� 1AAL, 1 Print Name: Dvnno-� Nzc, Title: Date: 9�c? hKL ;V I 13 Q:Purchas"idDoes/11-10944-DT Contract Print Na104c�ejon dei � Title: f n D11rCFby-Kr' ��' �/iGr►'Yt i Date: '7-t-! M116 RFP 11 -10144 -DT, Self -Insured Health Care Auditing Services Resolution No. 2011-RO313 Cut along the outer border and affix this label to your sealed proposal envelope to identify it as a "Sealed Proposal" be sure to include the name of the company submitting the proposal. ,---------------------------------------------------------------- SEALED PROPOSAL • DO NOT OPEN RFP NO: 11 -10144 -DT SELF-INSURED HEALTHCARE CLAIM AUDITING SERVICES e , DUE DATE/TIME: May 26, 2011, 3:00 SUBMITTED BY: CONTACT PHONE NUMBER: --------------------------- Proposal must be addressed to: Marta Alvarez, Director of Purchasing and Contract Management City of Lubbock 1625 13th Street, Room 204 Lubbock, Texas 79401 Q:Purchase/Bid Docsl I 1- 10 144 -DT RFP 11-10144-D7", Self -Insured Health Care Auditing Services Self -Insured Health Care Auditing Services CITY OF LUBBOCK, TEXAS RFP 11 -10144 -DT Checklist Please ensure that you complete and return the following documents and information to the City of Lubbock Purchasing and Contract Management Department before the deadline. Any corrections must be initialed by person making the correction. Late submittals will not be accepted. FAILURE TO PROVIDE ANY OF THE ABOVE MAY RESULT IN YOUR PROPOSAL BEING DEEMED NON- RESPONSIVE. Invitation to Proposal Form MUST be completed Print Name of Company. 1 Contact Person/Phone PLEASE INCLUDE THIS COMPLETED PAGE AS THE FIRST PAGE OF YOUR SUBMITTAL. Q:PurchaseBid Docs/11-10144-DT 2 The Request for Proposal Form MUST be completed in blue or black ink or by typewriter. Signatures must be original, in blue or black ink, and by hand. Include firm's FEDERAL TAX ID number or SOCIAL SECURITY number. (Page 4). Clearly mark the RFP number, title, due date and time, and your company name and address on the outside of the sealed envelope or container. Completed and signed SUSPENSION AND DEBARMENT CERTIFICATION. Please include Company Federal TAX Id number or Social Security number. (Page 21) Insurance Requirement Affidavit (Page 22) Consideration of Location of Bidder's Principal Place of Business Affidavit of Eligibility form (if applicable). (Page 23) Please return original and three copies of the sealed proposal. FAILURE TO PROVIDE ANY OF THE ABOVE MAY RESULT IN YOUR PROPOSAL BEING DEEMED NON- RESPONSIVE. Invitation to Proposal Form MUST be completed Print Name of Company. 1 Contact Person/Phone PLEASE INCLUDE THIS COMPLETED PAGE AS THE FIRST PAGE OF YOUR SUBMITTAL. Q:PurchaseBid Docs/11-10144-DT 2 RFP 11 -10144 -DT, Self -Insured Health Cue Auditing Services Self -Insured Health Care Auditing Services CITY OF LUBBOCK, TEXAS RFP 11 -10144 -DT In an effort to better serve the business community, the City of Lubbock Purchasing and Contract Management Department is conducting the following survey. We appreciate the time and effort expended to submit your offer. Please take an additional moment to complete the information below. If you have any questions or need more information, please call (806)775-2572, HOW DID YOU RECEIVE NOTICE OF THIS REQ VEST FOR PROPOSALS? Lubbock Avalanche Journal? Yes No City of Lubbock Channel 2 Yes No From Plan Room or other type of service? Yes No Did you access the City of Lubbock website to search for Proposals? Yes No Facsimile or email from bidsync.com? Yes No Did you download from your home computer? Yes No Did you download from your company computer? Yes No Requested a copy from Lubbock Purchasing and Contract Management Department? Yes No Are you a member of Bid Sync? Yes No Other: Please include this page with your submittal. THANK YOU. Q:Purchase/Bid 11 -Docs/ 1 -10144 -DT 3 RFP 11 -10144 -DT, Self -Insured Health Care Auditing Services SUBMIT TO: CITY OF LUBBOCK ' ity of fl'ubbo& CITY OF LUBBOCK., TEXAS Purchasing & Contract Management 1625 Rm 204 ruts REQUEST FOR `•C Lubbock,Street, ck, Tx 79401-3830 AN EQUAL PROPOSAL CONTACT PERSON: D'Ana Torres OPPORTUNITY YER 11 -10144 -DT TEL: 806.775.2167 FAX: 806.775.2 l 64 http://purchasing.ei.lubbock.tx.us TITLE: Self -Insured Health Cale Auditing Services SUBMITTAL DEADLINE: May 26, 2011 at 3:00 P.M. CST PRE PROPOSAL MEETING DATE, TIME AND LOCATION: May 17, 201 1 .Any proposals received alter the time and date listed above, regardless at 10:00 at Ci Hall, Room 204, Lubbock, TX 79401 of the mode ojdelivery. shall be returned unopened. RESPONDENT NAME: IF RETURNING AS A "NO RESPONSE", PLEASE STATE REASON. MAILING ADDRESS: CITY — STATE — ZIP: THE CITY OF LUBBOCK RESERVES THE RIGHT TO ACCEPT OR REJECT ANY AND ALL PROPOSALS IN WHOLE OR IN PART AND WAIVE ANY INFORMALITY IN THE COMPETITIVE PROPOSAL PROCESS. FURTHER, THE CITY TELEPHONE NO: RESERVES THE RIGHT TO ENTER INTO ANY CONTRACT DEEMED TO BE IN THE BEST INTEREST OF THE CITY. IT IS THE INTENT AND PURPOSE OF THE CITY OF LUBBOCK THAT THIS FAX NO: REQUEST PERMITS COMPETITIVE PROPOSALS. IT IS THE OFFEROWS RESPONSIBILITY TO ADVISE THE CITY OF LUBBOCK DIRECTOR OF E-MAIL: PURCHASING AND CONTRACT MANAGEMENT IF ANY LANGUAGE, REQUIREMENTS, ETC., OR ANY COMBINATIONS THEREOF, FEDERAL TAX ID NO. OR SOCIAL SECURITY NO. INADVERTENTLY RESTRICTS OR LIMITS THE REQUIREMENTS STATED IN THIS RFP TO A SINGLE SOURCE, SUCH NOTIFICATION MUST BE SUBMITTED IN WRITING AND MUST BE RECEIVED BY THE DIRECTOR OF PURCHASING AND CONTRACT MANAGEMENT NO LATER THAN FIVE S BUSINESS DAYS PRIOR TO THE ABOVE SUBMITTAL DEADLINE. THE OFFEROR HEREBY ACKNOWLEDGES RECEIPT OF AND AGREES ITS PROPOSAL IS BASED ON ANY ADDENDA POSTED ON BIDSYNC.COM The City of Lubbock Charter states that no officer or employee of the City can benefit from any contract, job, work or service for the municipality or be interested in the sale to the City of any supplies, equipment, material or articles purchased. Will any officer or employee of the City, or member of their immediate family, benefit from the award of this proposal to the above firm? YESe NO IN COMPLIANCE WITH THIS SOLICITATION, THE UNDERSIGNED OFFEROR HAVING EXAMINED THE REQUEST FOR PROPOSAL, AND BEING FAMILIAR WITH THE CONDITIONS TO BE MET, HEREBY SUBMITS THE FOLLOWING. AN INDIVIDUAL AUTHORIZED TO BIND THE COMPANY MUST SIGN THE FOLLOWING SECTION. FAILURE TO EXECUTE THIS PORTION MAY RESULT IN PROPOSAL REJECTION. By my signature I certify that this offer is made without prior understanding, agreement, or connection with any corporation, firm, business entity, or person submitting an offer for the same materials, supplies, equipment, or service(s), and is in all respects fair and without collusion or fraud. I further agree that if the offer is accepted, the offeror will convey, sell, assign, or transfer to the City of Lubbock all right, title, and interest in and to ail causes of action it may now or hereafter acquire under the Anti-trust laws of the United States and the State of Texas for price fixing relating to the particular commodity(s) or service (s) purchased or acquired by the City of Lubbock. At the City's discretion, such assignment shall be made and become effective at the time the City tenders final payment to the vendor. Authorized Signature Title Print/Type Name Date THIS FORM MUST BE COMPLETED AND RETURNED WITH YOUR RESPONSE. Q:Purchase/Bid Docs/11-10144-DT RFP l I -10144 -DT, Sclf-Ensured Health Care Auditing Services Self -Insured Health. Care Auditing Services CITY OF LUBBOCK, TEXAS RFP 11 -10144 -DT The City of Lubbock appreciates your time and effort in preparing your proposal. All offerors should familiarize themselves with the following INSTRUCTIONS TO OFFERORS and GENERAL REQUIREMENTS: I. INSTRUCTIONS TO OFFERORS PROPOSAL DELIVERY, TIME & DATE 1.1 The City of Lubbock will receive written and sealed competitive proposals for Self -Insured Health Care Auditing Services until 3:00 p.m. CST, May 26, 2011, if date/time stamped on or before 3:00 p.m, at the office listed below. Any proposal received after the date and hour specified will be rejected and returned unopened to the offeror. Each proposal and supporting documentation must be in a sealed envelope or container plainly labeled in the lower left-hand corner: "RFP 11 -10144 -DT, Self -Insured Health Care Auditing Services" and the closing date and time. Offerors must also include their company name and address on the outside of the envelope or container. Proposals must be addressed to: Marta Alvarez, Director of Purchasing and Contract Management City of Lubbock 1625 13th Street, Room 204 Lubbock, Texas 79401 1.2 Offerors are responsible for making certain proposals and proposed contracts are delivered to the Purchasing and Contract Management Department. Mailing of a proposal does not ensure that the proposal will be delivered on time or delivered at all. If offeror does not hand deliver proposal, we suggest that he/she use some sort of delivery service that provides a receipt. The City of Lubbock assumes no responsibility for errant delivery of proposals, including those relegated to a courier agent who fails to deliver in accordance with the time and receiving point specified. 1.3 Proposals will be accepted in person, by United States Mail, by United Parcel Service, or by private courier service. No proposals will be accepted by oral communication, telephone, electronic mail, telegraphic transmission, or telefacsimile transmission. THE CITY WILL NOT ACCEPT FAX PROPOSALS. 1.4 Proposals may be withdrawn prior to the above scheduled time set for closing. Alteration made before RFP closing must be initialed by offeror guaranteeing authenticity. 1.5 The City of Lubbock reserves the right to postpone the date and time for accepting proposals through an addendum, 1.6 A proposal will be subject to being considered irregular and may be rejected if it shows omissions, alterations of form, conditional alternate proposals, additions or alternates in lieu of the items specified, if the unit prices are obviously unbalanced (either in excess of or below reasonably expected values), or irregularities of any kind." Q:Purchase/Bid Does/11-10144-DT RFP 11 -10144 -DT. Self -Insured Health Care Auditing Services 2 PRE -PROPOSAL MEETING 2.1 For the purpose of familiarizing offerors with the requirements, answering questions, and issuing addenda as needed for the clarification of the Request for Proposal (RFP) documents, a 2re-2rol2osal meeting will be held at 10:00 a.m. MAY 17 2011 in Room 204 at Cijy Hall 1625 13 Street Lubbock Texas. All persons attending the conference will be asked to identify themselves and the prospective offeror they represent. 2.2 It is the offeror's responsibility to attend the pre -proposal meeting though the meeting is not mandatory. The City will not be responsible for providing information discussed at the pre - proposal meeting to offerors who do not attend the pre -proposal meeting. 2.3 The City of Lubbock does not discriminate against person with disabilities. City of Lubbock pre -proposal meetings are available to all persons regardless of disability. If you would like information made available in a more accessible format or if you desire assistance, please contact the City of Lubbock ADA Coordinator, 1625 13th Street, (806)775-2018 at least forty-eight (48) hours in advance of the conference. 3 CLARIFICATION OF REQUIREMENTS 3.1 It is the intent and purpose of the City of Lubbock that this request permits competitive proposals. It is the offeror's responsibility to advise the City of Lubbock Director of Purchasing and Contract Management if any language, requirements, etc., or any combinations thereof, inadvertently restricts or limits the requirements stated in this RFP to a singJe source. Such notification must be submitted in writing and must be received by the City of Lubbock Purchasing Office no later than five (5) business days prior to the proposal closing date. A review of such notifications will be made. 3.2 ALL REQUESTS FOR ADDITIONAL INFORMATION OR CLARIFICATION CONCERNING THIS REQUEST FOR PROPOSAL (RFP) MUST BE SUBMITTED IN WRITING NO LATER THAN FIVE (5) BUSINESS DAYS PRIOR TO THE PROPOSAL CLOSING DATE AND ADDRESSED TO: D'Ana Tones, Buyer City of Lubbock 1625 1311" Street Lubbock, Texas79401 Fax: (806) 775-2164 Email: [name]@mylubbock.us BidSync: www.bidsync.com 4 ADDENDA & MODIFICATIONS 4.1 Any changes, additions, or clarifications to the RFP are made by ADDENDA information available over the Internet at www.bidsync.com. We strongly suggest that you check for any addenda a minimum of forty-eight hours in advance of the response deadline. BUSINESSES WITHOUT INTERNET ACCESS may use computers available at most public libraries. 4.2 Any offeror in doubt as to the true meaning of any part of the RFP or other documents may request an interpretation thereof from the Purchasing and Contract Management Department. At the request of the offeror, or in the event the Purchasing and Contract Q:Purchase/Bid Docs/1 WO 144 -DT RFP 1140144 -DT, self -Insured Health Care Auditing services Management Department deems the interpretation to be substantive, the interpretation will be made by written addenda issued by the Purchasing and. Contract Management Department. Such addenda issued by the Purchasing and Contract Management Department will be available over the Internet at www.bidsync.com and will become part of the proposal package having the same binding effect as provisions of the original RFP. No verbal explanations or interpretations will be binding. In order to have a request for interpretation considered, the request must be submitted in writing and must be received by the City of Lubbock Purchasing and Contract Management Department no later than five (5) days prior to the proposal closing date. 4.3 The City does not assume responsibility for the receipt of any addendum sent to offerors. 5 EXAMINATION OF DOCUMENTS AND REQUIREMENTS 5.1 Each offeror shall carefully examine all RFP documents and thoroughly familiarize itself with all requirements prior to submitting a proposal to ensure that the proposal meets the intent of this RFP. 5.2 Before submitting a proposal, each offeror shall be responsible for making all investigations and examinations that are necessary to ascertain conditions and requirements affecting the requirements of this RFP. Failure to make such investigations and examinations shall not relieve the offeror from obligation to comply, in every detail, with all provisions and requirements of the Request for Proposal. G PROPOSAL COPIES 6.1 OFFEROR'S MUST SUBMIT THE ORIGINAL AND THREE COPIES OF THE SEALED PROPOSAL TO THE PURCHASING AND CONTRACT MANAGEMENT DEPARTMENT PRIOR TO RESPONSE DUE DATE/TIME. FAILURE TO SUBMIT; THE ADDITIONAL COPIES MAY RESULT IN THE PROPOSAL BEING DECLARED UNRESPONSIVE. The original must be clearly marked. "ORIGINAL" and the copies must be clearly marked "COPY"" 6.2 All proposals, responses, inquiries, or correspondence relating to or in reference to this RFP, and all electronic media, reports, charts, and other documentation submitted by offerors shall become the property of the City of Lubbock when received. 7 PROPOSAL PREPARATION COSTS 7.1 Issuance of this RFP does not commit the City of Lubbock, in any way, to pay any costs incurred in the preparation and submission of a proposal. 7.2 The issuance of this RFP does not obligate the City of Lubbock to enter into contract for any services or equipment. 7.3 All costs related to the preparation and submission of a proposal shall be paid by the proposer. 8 TRADE SECRETS, CONFIDENTIAL INFORMATION AND THE TEXAS PUBLIC INFORMATION ACT 8.1 If you consider any portion of your proposal to be privileged or confidential by statute or judicial decision, including trade secrets and commercial or financial information, clearly identify those portions. Q:Purchase/Bid Docs/11-10144-DT 7 RFP 11-14144DT. Self -Insured Health Care Auditing Services 8.2 Proposals will be opened in a manner that avoids disclosure of the contents to competing offerors and keeps the proposals secret during negotiations. All proposals are open for public inspection after the contract is awarded, but trade secrets and confidential information in the proposals are not open for inspection. Tex. Loc. Govt. Code 252.049(b) 8.3 The City of Lubbock will honor your notations of trade secrets and confidential information and decline to release such information initially, but please note that the final determination of whether a particular portion of your proposal is in fact a trade secret or commercial or financial information that may be withheld from public inspection will be made by the Texas Attorney General or a court of competent jurisdiction. In the event a public information request is received for a portion of your proposal that you have marked as being confidential information, you will be notified of such request and you will be required to justify your legal position in writing to the Texas Attorney General pursuant to Section 552.305 of the Government Code. In the event that it is determined by opinion or order of the Texas Attorney General or a court of competent jurisdiction that such information is in fact not privileged and confidential under Section 552.110 of the Government Code and Section 252.049 of the Local Government Code, then such information will be made available to the requester. 8.4 Marking your entire proposal CONFIDENTIAUPROPRIETARY is not in conformance with the Texas Open Records Act. 9 DISADVANTAGED BUSINESS ENTERPRISE (DBE) REQUIREMENTS 9.1 The City of Lubbock hereby notifies all offerors that in regard to any contract entered into pursuant to this RFP, Disadvantaged Business Enterprises (DBE's) will be afforded equal opportunities to submit proposals and will not be discriminated against on the grounds of race, color, sex, disability, or national origin in consideration of an award. 9.2 A DBE is defined as a small business concern which is at least 51 % owned and controlled by one or more socially and economically disadvantaged individuals, or in the case of any publicly owned business, at least 51 % of the stock of which is owned by one ore more socially and economically disadvantaged individuals. Socially and economically disadvantaged include Women, Black Americans, Hispanic Americans, Native Americans, Asian -Pacific Americans, and Asian -Indian Americans. 10 HISTORICALLY UNDERUTILIZED BUSINESS (HUB) REQUIREMENTS 10.1 The City of Lubbock hereby notifies all offerors that in regard to any contract entered into pursuant to this RFP, Historically Underutilized Businesses (HUB's) will be afforded equal opportunities to submit proposals and will not be discriminated against on the grounds of race, color, sex, disability, or national origin in consideration of an award. 10.2 A HUB is defined as a small business concern which is at least 51% owned and controlled by one or more socially and economically disadvantaged individuals, or in the case of any publicly owned business, at least 51% of the stock of which is owned by one ore more socially and economically disadvantaged individuals. Socially and economically disadvantaged include Women, Black Americans, Hispanic Americans, Native Americans, Asian -Pacific Americans, and Asian -Indian Americans. Q:P=haseBid Docs/11-10144-DT 8 RFP 11 -10144 -DT, Self -Insured Health Care Auditing Services 11 CONFLICT OF INTEREST 11.1 The Offeror shall not offer or accept gifts or anything of value nor enter into any business arrangement with any employee, official or agent of the City of Lubbock. 11.2 By signing their proposal, the offeror certifies and represents to the City the offeror has not offered, conferred or agreed to confer any pecuniary benefit or other thing of value for the receipt of special treatment, advantage, information, recipient's decision, opinion, recommendation, vote or any other exercise of discretion concerning this RFP. 12 ANTI -LOBBYING PROVISION 12.1 DURING THE PERIOD BETWEEN PROPOSAL SUBMISSION DATE AND THE CONTRACT AWARD, PROPOSERS, INCLUDING THEIR AGENTS AND REPRESENTATIVES, SHALL NOT DIRECTLY DISCUSS OR PROMOTE THEIR PROPOSAL WITH ANY MEMBER OF THE LUBBOCK CITY COUNCIL OR CITY STAFF EXCEPT UPON THE REQUEST OF THE CITY OF LUBBOCK PURCHASING DEPARTMENT IN THE COURSE OF CITY -SPONSORED INQUIRIES, BRIEFINGS, INTERVIEWS, OR PRESENTATIONS. 12.2 This provision is not meant to preclude offerors from discussing other matters with City Council members or City staff. This policy is intended to create a level playing field for all potential offerors, assure that contract decisions are made in public, and to protect the integrity of the RFP process. Its purpose is to stimulate competition, prevent favoritism and secure the best work and materials at the lowest practicable price, for the best interests and benefit of the taxpayers and property owners. Violation of this provision may result in rejection of the offeror's proposal. 13 AUTHORIZATION TO BIND SUBMITTER OF PROPOSAL Proposals must show vendor name and address of offeror. The original proposal must be manually signed by an officer of the company having the authority to bind the submitter to its provisions. Person signing proposal must show title or AUTHORITY TO BIND THEIR FIRM IN A CONTRACT. Failure to manually sign proposal will disqualify it. 14 ABOUT THIS DOCUMENT This document is a Request for Proposal. It differs from an Request for Proposal in that the City of Lubbock is seeking a solution, as described in the following General Requirements section, not a bid/quotation meeting firm specifications for the lowest price. As such, the lowest price proposed will not guarantee an award recommendation. Sealed proposals will be evaluated based upon criteria formulated around the most important features of a product or service, of which quality, testing, references, availability or capability, may be overriding factors, and price may not be determinative in the issuance of a contract or award. The proposal evaluation criteria should be viewed as standards that measure how well an offeror's approach meets the desired requirements and needs of the City of Lubbock. Those criteria that will be used and considered in evaluation for award are set forth in this document. The City will thoroughly review all proposals received. The City will also utilize its best judgment when determining whether to schedule a pre -proposal conference (before proposals are accepted), or meetings with offerors (after receipt of all proposals). A Purchase Order/Contract will be awarded to a qualified offeror submitting the best proposal. The City reserves the right to select, and subsequently recommend for an award, Q:Purchase/Bid Docs/I 1 -10144 -DT 9 RFP 11 -10144 -DT. Self-insured Health Cam Auditing Services the proposed service which best meets its required needs, quality levels, and budget constraints. 15 EVALUATION PROCESS 15.1 All proposals will be evaluated by an evaluation committee and may include senior management representatives, a financial officer, and/or an independent consultant. 15.2 Respondents to this RFP may be required to submit additional information that the City may deem necessary to further evaluate the offeror's qualifications. 15.3 The committee will evaluate and numerically score each proposal in accordance with the evaluation criteria included in the Request for Proposal. 15.4 The committee will arrive at a short list of the top respondents and these short-listed respondents may be scheduled for a structured oral presentation and interview. Such presentations will be at no cost to the City of Lubbock. At the end of the oral presentation and interview, the evaluation of the short-listed respondents will be completed. The oral interview may be recorded and/or videotaped. 16 SELECTION 16.1 Selection shall be based on the responsible offeror whose proposal is determined to be the most advantageous to the City of Lubbock considering the relative importance of evaluation factors included in this RFP. 16.2 NO INDIVIDUAL OF ANY USING DEPARTMENT HAS THE AUTHORITY TO LEGALLY AND/OR FINANCIALLY COMMIT THE CITY TO ANY CONTRACT, AGREEMENT OR PURCHASE ORDER FOR GOODS OR SERVICES, UNLESS SPECIFICALLY SANCTIONED BY THE REQUIREMENTS OF THIS REQUEST FOR PROPOSAL. 17 EQUAL EMPLOYMENT OPPORTUNITY Offeror agrees that it will not discriminate in hiring, promotion, treatment, or other terms and conditions of employment based on race, sex, national origin, age, disability, or in any way violative of Title VII of 1964 Civil Rights Act and amendments, except as permitted by said laws. 18 NONAPPROPRIATION All funds for payment by the City under this contract are subject to the availability of an annual appropriation for this purpose by the City. In the event of non -appropriation of funds by the City Council of the City of Lubbock for the goods or services provided under the contract, the City will terminate the contract, without termination charge or other liability, on the last day of the then - current fiscal year or when the appropriation made for the then -current year for the goods or services covered by this contract is spent, whichever event occurs first. If at any time funds are not appropriated for the continuance of this contract, cancellation shall be accepted by the Seller on thirty (30) days prior written notice, but failure to give such notice shall be of no effect and the City shall not be obligated under this contract beyond the date of termination. 19 PROTEST 19.1 All protests regarding the RFP process must be submitted in writing to the City Director of Purchasing and Contract Management within five (5) business days following the opening of proposals. This includes all protests relating to advertising of notices, deadlines, proposal QTurchase/Bid Docs/11-10144-DT 10 RFP 11 -10144 -DT, Self -Insured Health Care Auditing Services opening, and all other related procedures under the Local Government Code, as well as any protest relating to alleged improprieties with the RFP process. This limitation does not include protests relating to staff recommendations as to award of contract. Protests relating to staff recommendations may be directed to the City Manager. All staff recommendations will be made available for public review prior to consideration by the City Council as allowed by law. 19.2 FAILURE TO PROTEST WITHIN THE TIME ALLOTTED SHALL CONSTITUTE A WAIVER OF ANY PROTEST. 20. THE CITY RIGHT TO AUDIT At any time during the term of the contract, or thereafter, the City, or a duly authorized audit representative of the City or the State of Texas, at its expense and at reasonable times, reserves the right to audit Contractor's records and books relevant to all services provided to the City under this Contract. In the event such an audit by the City reveals any errors or overpayments by the City, Contractor shall refund the City the full amount of such overpayments within thirty (30) days of such audit findings, or the City, at its option, reserves the right to deduct such amounts owing the City from any payments due Contractor. The City of Lubbock is aware of the time and effort you expend in preparing and submitting proposals to the City. Please let us know of any requirement causing you difficulty in responding to our Request for Proposal. We want to facilitate your participation so that all responsible firms can compete for the City's business. Awards should be made approximately two to six weeks after the opening date. Ifyou have any questions, please contact the City of Lubbock Director of Purchasing and Contract Management at (806) 775-2572. Q;Purehase/Bid Does/11-10144-DT 11 11. GENERAL REQUIREMENTS 1 INTENT RFP 11 -14144 -DT, Self -Insured Health Care Auditing Services The City of Lubbock (hereinafter called "City") is seeking proposals from interested firms and individuals, (hereinafter called "Proposer") to provide Self -Insured Health Care Auditing Services. 2 PROJECT DESCRIPTION Background In January 2007, The City of Lubbock changed their third party administrator (TPA) for it's self-funded health insurance program. For the 2009 plan year, there were approximately 2,515 subscribers plus approximately 2,863 dependents in the program. For 2010, there were approximately 2,570 subscribers plus approximately 2,929 dependents in the program. Blue Cross Blue Shield of Texas (BCBS) provided the Administrative Services Only (ASO) for medical and dental coverage for 2009, 2010, and 2011 plan years. BCBS provided one PPO plan with Blue Choice to the subscribers and dependents. BCBS was not the Pharmacy Benefits manger (PMB) during any of the plan years. The PBM for all years was Maxor Plus. HM Life provided the individual and aggregate stop loss insurance for all five plan years. The City provides health benefits to pre -Medicare and Medicare eligible retirees. The plan is financed on a self-funded basis where weekly medical, dental, and pharmaceutical claims for the City plan are paid. For the 2009 plan year, 40,706 medical service claims, 6,242 dental claims, and 60,270 pharmacy claims costs totaling $18,039,468. For 2010 plan year, 48,186 medical service claims, 6,597 dental claims, and 61,563 pharmacy claims paid totaling $21,504,090. For the current 2011 plan year, approximately 10,806 medical claims, 1,660 dental claims, and 15,961 pharmacy claims have been paid as of March 31, 2011 for a total of $5,760,474. In addition, The City had individual stop -loss insurance to mitigate risk when claims reach over $250,000 for plan year 2009, and a $356,000 for plan years 2010 and 2011 per individual covered. Standard medical ASO fees, and individual and aggregate stop loss insurance premiums, are invoiced by HM Life and paid on a monthly basis. 3 PURPOSE OF THE PROJECT It is the intent of the City to verify that the TPA and PBM have been administering the City of Lubbock Health Benefit Plan in accordance with the terms of the contracts in place at the time of claim adjudication. All data files necessary for testing will be requested from BCBS and Maxor by the Proposer. Additionally, eligibility verification for the claim population will be confirmed by the City. Provided below is a list of areas that will be expected to be covered in the audit. Due to the period being audited and the changes in contracts, please provide the recommended sample technique and size. The Proposer may recommend additional testing areas as appropriate. 4 SCOPE OF WORK QTurehase/Bid DDesll1-10144-DT 12 RFP 11 -10144 -DT, Self -Insured Health Care Auditing Services Services requested in this RFP include, but are not limited to, reviews of the following: Medical Claims Processing and Payments Through analysis of paid medical claims data received from the TPA for the 2009, 2010, and 2011 plan years: (a) Determine whether any claimants met the requirements to apply for stop loss insurance during the audit period. (b) Determine whether any claimant's annual/lifetime maximums were reached and whether the appropriate action was taken. (c) Identify potential duplicate payments, including claims for the same services with different procedure codes. (d) Perforin an analysis of procedure codes taking into consideration all elements that affect pricing (provider type, point of service, diagnosis, secondary diagnosis, etc.) and identify questionable variances. Report variances to the Human Resources staff and assist in determining cause and recommending possible steps for resolution. (e) For all plan years, review performance standards included in the contract between BCBS and The City and determine whether the stated benchmarks were met. (f) For all plan years, review cumulative claims data and determine whether annual network provider discount targets included in the contact between BOBS and the City were met. (g) Proved sufficient evidence (such as copies of billing errors, coding errors, etc.) to substantiate any errors. (h) For the plan year 2011, review claims data and determine that claims were paid in accordance with the City's desire to remain grandfathered. For a sample of medical claims, perform a detailed line item review of provider billings to include the following tests: • Verify the provider status on the date of service as being In Network or Out of Network. • Re -adjudicate the claims sampled as appropriate. Tests should include a review of pricing, verifying that procedure codes on the date of service were for benefits covered under the plan, look for potential upcoding or unbundling, inappropriate CCI edits and OCE edits, mutually exclusive codes, sex inappropriate procedure codes, excessive billed quantities, etc. Review contracts as necessary. • Verify that sufficient documentation was provided to support the claim payment and an adequate review was performed, taking into consideration the claim dollar amount. • Determine whether the proper application of deductibles and/or timely coordination of benefits and subrogation took place (integration with Medicare, third party liability, duplicate coverage, and worker's compensation), including retirees and active employees over the age of 65. For identified claims, where it is applicable, determine if funds were received and applied to the City or were deducted from the bill accurately. • For plan all plan years, determine whether claims were submitted by the provider and paid by BCBS in accordance with performance contract standards for health benefits terms, including timeliness, financial accuracy, and procedural accuracy. QTurchas6Bid Docs/11-10144-DT 13 RR 11 -16144 -DT, Self-insured Health Care Auditing Services • Provide sufficient evidence (such as copies of billing errors, coding errors, etc.) to substantiate any errors. Dental Claims Processing and Payments Through analysis of paid dental claims data received from the TPA for the 2009, 2010, and 2011 plan years: • Identify potential duplicate payments. • Determine whether any claimant's annual/lifetime maximums were reached and whether the appropriate action was taken. • Identify potential duplicate payments, including claims for the same services with different procedure codes. • Provide sufficient evidence to substantiate any errors. For a sample of dental claims, perform these additional tests: • Determine whether dental claims were paid according to the agreed upon discount arrangements and reimbursement rates and assigned to the appropriate tier for payment. • Re -adjudicate the claims sampled as appropriate. Tests should include a review of pricing, verifying that procedure codes on the date of service were for benefits covered under the plan, look for potential excessive billed quantities, etc. Review contracts as necessary. • Provide sufficient evidence (such as copies of billing errors, coding errors, etc.) to substantiate any errors. Pharmaceutical Claims Processiniz and Payments Through analysis of paid pharmaceutical claims data received from the TPA for the 2009, 2010, and 2011 plan years: • Identify potential duplicate payments. • For all plan years, ensure rebates were credited according to contract terms. • Provide sufficient evidence to substantiate any errors. For a sample of pharmaceutical claims, perform these additional tests: • Determine whether pharmaceutical claims were paid according to the agreed upon discount arrangements and reimbursement rates and assigned to the appropriate tier for payment. • Determine calculation accuracy including ingredient costs and dispensing fees. • Provide sufficient evidence (such as copies of billing errors, coding errors, etc.) to substantiate any errors. When fieldwork is complete, review the results with BOBS and Maxor then meet with the City to present the results of the audit and assist with securing any corrective action necessary. Communication and Collaboration with City Human Resources Staff Q:Pur+cnase/Bid Docs/1 140144 -DT 14 RFP 11 -10144 -dT, Self -Insured Health Care Auditing Services City Human Resources staff may accompany the winning Proposer to the audit site. The Human Resources staff will expect progress reports throughout the engagement and, at the discretion of Human Resources, some of the progress report information will be requested in writing. These reports will include details of issues to date. Also, it is expected that the Human Resources staff may consult with the Proposer's staff as the need arises and after the audit has been performed. The selected Proposer will be requested to provide a copy of all electronic data obtained during the course of the audit in a delimited text file (including the table definition that describes the data elements), as legally permitted per BCBS and Maxor contracts. Deliverables A final report will be presented to the City which should include, although not be limited to, the following: • A projection of the range of the total dollar population of claims paid for the audit period determined statistically from the sampling results and the sampling criteria for each calendar year audited. • A projection of total errors in the population based on the sampling results (by plan year), including the methodology used for the projection. • A schedule of known errors with sufficient detail to present to BCBS and/or Maxor for refund or settlement, including the cause(s) of the error, if determinable. The dollar amount of the error should be presented in a format that will indicate a detailed description of the claim, the original amount paid, amount per audit the difference between the original amount paid and amount per audit, and explanation of the error. • Specific recommendations on processes and procedures to prevent and detect future errors. 5 PROJECT METHODOLOGY The proposal should include the recommended sample size based on the following approximate number and value ad claims paid: • 40,706 medical service claims, 6,242 dental service claims, and 60,270 pharmacy claims paid for the 2009 plan year totaling $18 million • 48,186 medical service claims, 6,597 dental service claims, and 61,563 pharmacy claims paid for the 2010 plan year totaling $21.5 million • 10,806 medical service claims, 1,660 dental service claims, and 15,961 pharmacy claims paid through March 31, 2011 for the plan year 2011 totaling $5.7 million. This should include how the sample will be selected to ensure sufficient coverage of high risk claims as well as the number of strata used and the dollar range of each stratum in the sampling methodology, if applicable. In addition, a description of the methodology that will be used to extrapolate the sample audit results across the entire population shall be provided. The following statistical parameters should be used for each sample from each plan year: Confidence Level: 95% Reliability (Precision): +/-2% Q:PurchaWBid Do&II-10144-DT 15 RFP 11 -10144 -DT, Self-insured Health Care Auditing Services Expected Error Rate: Less than 5% Sample reports including the deliverable stated in Section 1. C., should be provided with the proposal. Alternatives to the deliverables stated may also be presented for consideration. Firms should list any prior work within the past five years where the firm either engaged in business with BOBS or Maxor or any subsidiaries or organizations related to these two companies. The firm should detail the services performed and the fee received. 6 EVALUATION CRITERIA A Proposer may propose on all activities that it considers itself qualified to review. Proposer(s) will be selected based upon the criteria set forth in the RFP. Qualifications will be judged in the area of expertise and cited by the response of this RFP. Any subcontractor must be identified in the initial proposal, including the name of the firm and all other information as required of the principal firm in this RFP. The City reserves the right to reject any proposed subcontractors. Once a contract is entered into with the successful Proposer, no additional subcontracting will be allowed without the express prior written consent of the City. b) Offerors are invited to submit demonstrated competence and qualifications of their firm for providing these services. c) The information contained within this document is intended to provide interested firms with the requirements and criteria that will be used to make the selection. The following criteria will be used to evaluate and rank submittals: a) Substantial successful experience in competing similar projects that includes representations regarding the firm's qualifications and demonstrated skill appropriate to this project and the technical capabilities and professional competence of the Proposer and assigned personnel. (30%) b) Record of performance on similar projects based on previous work with the City and/or other client references. (25%) C) Cost. (25%) d) Substantial capability to meet schedules and deadlines as well as the capability to complete projects without having major cost escalations, change orders or overruns. (20%) 8 PROPOSAL FORMAT a) Proposals should provide a straightforward, concise description of the Offeror's capabilities to satisfy the requirements of the RFP. Emphasis should be on completeness, clarity of content, and conveyance of the information requested by the City. Q:Pmrehase/Bid Docs/1 t-1Ot44-DT 16 RFP 11-10144DT, Self insured Health Care Auditing Services b) The proposal should be bound in a single volume where practical. All documentation submitted with the proposal should be bound in that single volume, notebooks preferred. C) If the proposal includes any comment over and above the specific information requested in the RFP, it is to be included as a separate appendix to the proposal. d) The proposal must be organized into the following response item sections and submitted in an indexed binder. i) Cover letter addressed to the Honorable Mayor and City Council that states the Offeror's understanding of the services to be provided. Include any additional information believed necessary that is not requested elsewhere in the RFP. ii) A description of the methodology to be used to complete the project to include, but not be limited to, how recommendations will be formulated and commitment of adequate appropriate resources to the project. iii) Offeror's specific expertise in areas pertinent to the project to include a listing and brief description of similar projects completed (with the dates of completion) or in progress and a list of references by name, address, and telephone number for each project listed. This list of projects in progress shall include the phase of work that each project is currently in (i.e. design, bid, construction), and the estimated completion date. iv) A brochure of past work, with emphasis on comparable projects. v) List of principal(s) of the Proposer and amount of time that principal(s) will be involved in the project. vi) List of other professionals to be used, if applicable, with a record of experience in projects of this nature. Identification of principal(s) and percentage of time the principal(s) will be involved in the project. vii) The organizational structure of the employees who will be assigned to this project along with resumes of those individuals. If a joint venture is expected, then provide the organizational structure of the sub -contractor and resumes of those persons who will be involved in the project. viii) The Proposer must assure the City that he/she will to the best of his/her knowledge, information and belief, be cognizant of, comply with, and enforce, where applicable and to the extent required, all applicable federal or state statutes and local ordinances including, but not limited to the Davis -Bacon Federal minimum wage requirements. ix) Describe the Offeror's methodology for handling errors and omissions. x) Disclosure of any obligations posing a potential conflict of interest, including service on City boards and/or commissions and any current contracts with the City of Lubbock. This would apply to the Proposer as well as consultants subcontracted by the Proposer. Q:Purchasei id Does/11-14144-DT 17 RFP 11 -10144 -DT. Self -Insured Health Cam Auditing Services xi) Any material which the proponent wishes to submit and which is not specifically requested in the above categories. xii) Offerors are strongly encouraged to explore and implement methods for the utilization of local resources, and to outline how they would address outreach issues in their proposal. It is also the desire of the City that the City of Lubbock program serve, as much as practicable, to stimulate growth in all sectors of the local business community. Describe how your firm would facilitate this process, and provide any relevant information about similar efforts on previous projects. Q:Purohase/Bid Docs/11-10144-DT 18 RFP 11 -10144 -DT, Self -Insured Health Care Auditing Services Self -Insured Health Care Auditing Services CITY OF LUBBOCK, TEXAS RFP 11 -10144 -DT II. INSURANCE SECTION A. Prior to the approval of this contract by the City, the Contractor shall furnish a completed Insurance Certificate to the City, which shall be completed by an agent authorized to bind the named underwriter(s) to the coverages, limits, and termination provisions shown thereon, and which shall furnish and contain all required information referenced or indicated thereon. THE CITY SHALL HAVE NO DUTY TO PAY OR PERFORM UNDER THIS CONTRACT UNTIL SUCH CERTIFICATE SHALL HAVE BEEN DELIVERED TO THE CITY. INSURANCE COVERAGE REQUIRED SECTION B. The City reserves the right to review the insurance requirements of this section during the effective period of the contract and to require adjustment of insurance coverages and their limits when deemed necessary and prudent by the City based upon changes in statutory law, court decisions, or the claims history of the industry as well as the Contractor. SECTION C. Subject to the Contractor's right to maintain reasonable deductibles in such amounts as are approved by the City, the Contractor shall obtain and maintain in full force and effect for the duration of this contract, and any extension hereof, at Contractor's sole expense, insurance coverage written by companies approved by the State of Texas and acceptable to the City, in the following type(s) and amount(s): TYPE AMOUNT 1. Workers' Compensation and Employers Liability Insurance: Contractor shall elect to obtain workers' compensation coverage pursuant to Section 406.002 of the Texas Labor Code. Further, Contractor shall maintain said coverage throughout the term of this Lease and shall comply with all provision of Title 5 of the Texas Labor Code to ensure that the Contractor maintains said coverage. Any termination of workers' compensation insurance coverage by Contractor or any cancellation or non -renewal of workers' compensation insurance coverage for the Contractor shall be a material breach of this contract. The policy must be endorsed to include a waiver of subrogation in favor of the City of Lubbock. Employer's Liability with limits of at least $500,000 each accident, $500,000 by disease policy limit, and $500,000 by disease each employee shall also be obtained and maintained throughout the term of this Lease. 2. Commercial General (public) Liability insurance including coverage for the following: a. Products/completed operations b. Personal injury c. Advertising injury d. Contractual liability Combined single limit for bodily injury and property damage of $500,000 per occurrence or its equivalent. The City of Lubbock shall be named a primary additional insured with a waiver of subrogation in favor of the City on all coverage's. All copies of the Certificates of Insurance shall reference the RFP or proposal number for which the insurance is being supplied. Q:Purchase/Bid Docs/11-10144-DT 19 RFP 11 -10144 -DT, Self -Insured Health Care Auditing Services ADDITIONAL POLICY ENDORSEMENTS The City shall be entitled, upon request, and without expense, to receive copies of the policies and all endorsements thereto and may make any reasonable request for deletion, revision, or modification of particular policy terms, conditions, limitations, or exclusions (except where policy provisions are established by law or regulation binding upon either of the parties hereto or the underwriter of any of such policies). Upon such request by the City, the Contractor shall exercise reasonable efforts to accomplish such changes in policy coverages, and shall pay the cost thereof. REQUIRED PROVISIONS The Contractor agrees that with respect to the above required insurance, all insurance contracts and certificate(s) of insurance will contain and state, in writing, on the certificate or its attachment, the following required provisions: a. Name the City of Lubbock and its officers, employees, and elected representatives as additional insureds, (as the interest of each insured may appear) as to all applicable coverage; b. Provide for 30 days notice to the City for cancellation, nonrenewal, or material change; c. Provide for notice to the City at the address shown below by registered mail; d. The Contractor agrees to waive subrogation against the City of Lubbock, its officers, employees, and elected representatives for injuries, including death, property damage, or any other loss to the extent same may be covered by the proceeds of insurance; e. Provide that all provisions of this contract concerning liability, duty, and standard of care together with the indemnification provision, shall be underwritten by contractual liability coverage sufficient to include such obligations within applicable policies. f. All copies of the Certificates of Insurance shall reference the project name or proposal number for which the insurance is being supplied. NOTICES The Contractor shall notify the City in the event of any change in coverage and shall give such notices not less than 30 days prior the change, which notice must be accompanied by a replacement CERTIFICATE OF INSURANCE. All notices shall be given to the City at the following address: Marta Alvarez, Director of Purchasing and Contract Management City of Lubbock 1625 13th Street, Room 204 Lubbock, Texas 79401 SECTION D. Approval, disapproval, or failure to act by the City regarding any insurance supplied by the Contractor shall not relieve the Contractor of full responsibility or liability for damages and accidents as set forth in the contract documents. Neither shall the bankruptcy, insolvency, or denial of liability by the insurance company exonerate the Contractor from liability. Q:Purchase/Bid Docs/l 1 -10144 -DT 20 RFP 11 -10144 -DT, $elf -Insured Health Cane Auditing Services SUSPENSION AND DEBARMENT CERTIFICATION Federal Law (A-102 Common Rule and OMB Circular A-110) prohibits non -Federal entities from contracting with or making sub -awards under covered transactions to parties that are suspended or debarred or whose principals are suspended or debarred. Covered transactions include procurement contracts for goods or services equal to or in excess of 525,000 and all non -procurement transactions (e.g., sub -awards to sub -recipients). Contractors receiving individual awards of $25,000 or more and all sub -recipients must certify that their organization and its principals are not suspended or debarred by a Federal agency. Before an award of $25,000 or more can be made to your firm, you must certify that your organization and its principals are not suspended or debarred by a Federal agency. 1, the undersigned agent for the firm named below, certify that neither this firm nor its principals are suspended or debarred by a Federal agency. COMPANY NAME: Signature of Company Official: Date Signed: Printed name of company official signing above: Q:PurehaselBid Docs/11-10144-DT 21 RFP 11 -10144 -DT. Self-lusured Health Care Auditing Services CITY OF LUBBOCK, TEXAS Self -Insured Health Care Auditing Services RFP 11 -10144 -DT INSURANCE REQUIREMENT AFFIDAVIT To Be Completed by Offeror and Agent And Attached to Submittal 1, the undersigned Offeror, certify that the insurance requirements contained in this proposal document have been reviewed by me with the below identified Insurance Agent/Broker. If I am awarded this contract by the City of Lubbock, I will be able to, within ten (10) business days after being notified of such award by the City of Lubbock, furnish a valid insurance certificate to the City meeting all of the requirements defined in this proposal. If this time requirement is not met, the City has the right to reject the Offeror's proposal and award the contract to another Proposer. Offeror (Signature) Offeror (Print) Company Name (Print or Type) Company Address Name of AgentBroker (Print or Type) Address of Agent/Broker City. State, Zip: Phone Number Fax Number Email Address The City of Lubbock shall be named a primary additional insured with a waiver of subrogation in favor of the City on all coverage's. All copies of the Certificates of Insurance shall reference the RFP or proposal number for which the insurance is being supplied. If you have any questions concerning these requirements, please contact the Purchasing and Contract Management Department for the City of Lubbock at (806) 775-2572. The Proposer must complete, sign and return as part of their submittal response. Q:PurchaselBid Docs/11-10144-DT 22 RFP 11-10144DT. Self -Insured Health Care Auditing Services City of Lubbock Consideration of Location of Offeror's Principal Place of Business Affidavit of Eligibility Pursuant to Subchapter Z, Chapter 271, Texas Local Government Code, In purchasing under this title any real property, personal property that is not affixed to real property, or services, if a municipality receives one or more competitive sealed proposal from an offeror whose principal place of business is in the municipality and whose proposal is within five percent of the lowest proposal price received by the municipality from a offerors who is not a resident of the municipality, the municipality may enter into a contract for an expenditure of less than $100,000 with: (1) the lowest offerors; or (2) the offeror whose principal place of business is in the municipality if the governing body of the municipality determines, in writing, that the local offeror offers the municipality the best combination of contract price and additional economic development opportunities for the municipality created by the contract award, including the employment of residents of the municipality and increased tax revenues to the municipality. This section does not apply to the purchase of telecommunications services or information services, as those terms are defined by 47 U.S.C. Section 153. In order to receive consideration, offeror must submit this affidavit to: Marta Alvarez, Director of Purchasing And Contract Management City of Lubbock 1625 13's Street, Room 204 Lubbock, TX 79401 Complete all areas below. Incomplete affidavits may be rejected. Local Business Name: Local Address (must be within the City limits): Address of the company's principal place of business within the United States: I . How many residents of the City of Lubbock are employed at the above business location? 2. Year your business was established in the City of Lubbock: 3. For transactions that require sales tax, provide the following Reseller information: Reseller Permit Number: Company Name and Address (as it appears on permit): 4. Does your business have more than one office in the State of Texas? Yes No If Yes, identify the office location considered as the point -of sale credit for sales tax purposes: 5. Was the local business required to pay business and/or real property tax for the most recent tax year? Yes No If Yes, did the local business pay any of this tax to the City of Lubbock? Yes No Under penalty of perjury, the undersigned states that the foregoing statements are true and correct. It is further acknowledged that any person, firm, corporation or entity intentionally submitting false information to the City in an attempt to qualify for eligibility shall be prohibited from bidding on City of Lubbock products and services for a period of one (l) year. Authorized Signature: Printed Name and Title: Q:Purchase/Bid Docs/11-10144-DT 23 Date: